Provider Demographics
NPI:1952637753
Name:HERNANDEZ, MITCHELL JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:JOHN
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3606 KLONDIKE LANE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218
Mailing Address - Country:US
Mailing Address - Phone:502-451-3931
Mailing Address - Fax:502-451-3933
Practice Address - Street 1:3606 KLONDIKE LANE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218
Practice Address - Country:US
Practice Address - Phone:502-451-3931
Practice Address - Fax:502-451-3933
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-29
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY88171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice